Provider First Line Business Practice Location Address:
244 E ELLENDALE AVE STE 4
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DALLAS
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97338-1523
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-400-6994
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/29/2005